Clinical Review Lesson of the week

Deaths after delayed recognition of percutaneous endoscopic gastrostomy tube migration

BMJ 1998; 317 doi: (Published 22 August 1998) Cite this as: BMJ 1998;317:524
  1. Ian Botterill (, research fellow,
  2. Glenn Miller, lecturer,
  3. Simon Dexter, lecturer,
  4. Iain Martin, senior lecturer.
  1. Department of Surgery, Centre for Digestive Diseases, General Infirmary, Leeds LS1 3EX
  1. Correspondence to: Mr Botterill
  • Accepted 27 November 1997

If early leakage around a percutaneous endoscopic gastrostomy tube occurs, stop enteric feeding immediately and perform an endoscopy as soon as possible

Feeding by percutaneous endoscopic gastrostomy is an established method of maintaining enteral nutrition in patients with dysphagia. The procedure is straightforward and is associated with low mortality and morbidity. The most common complications are local infection and skin excoriation. Should late complications occur, the feeding tube can easily be exchanged as a fibrous track develops around it. We report two patients who developed leakage around the percutaneous endoscopic gastrostomy tube soon after it had been placed. Both developed fatal complications after seemingly minor adjustments to the tube had been made.

Case reports

Case 1

An 88 year old woman was admitted to hospital with a history of progressive dysphagia and weight loss over the previous six weeks. Findings at gastroscopy were normal, but a barium swallow showed oesophageal dysmotility. Because the patient had been malnourished for several weeks, it was agreed to place a percutaneous endoscopic gastrostomy tube for feeding purposes.

A percutaneous endoscopic gastrostomy tube (20 French gauge; CORFLO-Bower, CORPAK MedSystems, Wheeling, IL 60090, USA) was inserted, using the “pull” technique described by Gauderer.1 Prophylactic antibiotics were not given. The procedure was completed uneventfully, and a follow up endoscopy showed that the intragastric bumper was in a satisfactory position. In keeping with our protocol, the feeding tube was not used for 24 hours. Trial feeding with water was then begun, and enteral feeding was started after the water had been tolerated without abdominal …

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